Bay Area leaders wrestle with state’s new health equity measures


Some Bay Area public health leaders said Thursday that they remain unclear on how they will adhere to the state’s new “health equity” metric, intended to protect disadvantaged areas hardest hit by the coronavirus pandemic.

One official said the new metric — which counties must meet in order to move forward with economic reopening — is inadequate and unfair. But others said that even if it’s not a perfect solution, they understood the value in tracking the disparate impact of the pandemic on some communities, and especially people of color.

The health equity metric, which takes effect Tuesday, primarily relies on the positive test rate — the percent of coronavirus tests that come back positive, a statistic that is widely used as an indicator for when it’s safe to ease restrictions and reopen a local economy. Higher positive test rates indicate the virus is spreading more quickly.

“Health equity is important, but at the same time, tying it to a single measure doesn’t really paint the whole picture,” said Dr. Karen Relucio, the Napa County health officer. She said she supports the new metric even if she has concerns about how it may be applied.

The California Department of Public Health, which unveiled details of the new metric Wednesday evening, defended the new metric against complaints from some health officers that it puts an unreasonable burden on counties.

“The conditions that result in poorer health outcomes for communities of color are persistent and systemic,” state public health officials said in an email reply to questions about the metric. “An approach based on health equity will improve testing and services for COVID-19 patients who need it most, and in the long-term it will set the standard for how government can function.”

The state’s efforts to improve positive rates for disadvantaged communities comes at a time when counties are struggling to find a balance between public health concerns and economic reopening pressures. This new metric could pit community safety against business prosperity, if the stated goals prove hard to achieve.

Under the new metric, each county must ensure that positive test rates in its most disadvantaged neighborhoods do not significantly lag behind the county’s overall positive rate. For a county to advance to a less-restrictive tier, the disadvantaged neighborhoods — measured by a variety of social, health and economic factors — must come within 5% of the overall positive test rate required for that tier.

How the metric will affect Bay Area counties’ ability to progress toward reopening — and how exactly counties will respond to the complex requirement — remained in question in most places Thursday. But it appears that many regions will struggle to bridge large health disparities that mostly impact Latino, Black and Pacific Islander communities, particularly as testing lags in these communities.

In San Mateo, for example, the positivity rate for disadvantaged communities is 7.1%, compared with the county’s overall positivity rate of 3.7%. But Alameda County officials said Thursday that they are meeting the metric goals — the county’s overall positive test rate is 2.3%, and 3.8% for its at-risk communities.

Dr. Sara Cody, the Santa Clara County health officer, said she welcomes the new metric as a tool, and motivation, for improving spread of disease in communities of color.

“A county can’t move along until the least advantaged quartile is also ready to move along. It’s a no one is left behind type strategy, which I think is entirely appropriate, and really welcome,” Cody said.

She did not know Thursday the exact metric for her county, but she said the positive test rates for the overall county and lower-income communities — in particular, parts of east San Jose and the south county — were not far apart. She said the county had identified higher-risk communities early in the pandemic and made efforts to move testing and other resources there.

“We have been looking at our data and allocating resources accordingly to address disparities,” Cody said. “And we’re starting to see case rates come down and positivity rates come down. We’re starting to see some positive signals, which is a great relief. These communities need a break.”

In San Francisco, Dr. Grant Colfax, director of public health, said the city has similarly shifted resources to neighborhoods most affected by the pandemic, increasing access to testing and health care and support for those who need to isolate.

But some local public health officials said the measure is narrow in focus and tries to swiftly repair systemic health inequities and socioeconomic issues that have played out across the state for decades.

Solano County Health Officer Dr. Bela Matyas said Thursday the health equity measurement misses the mark because it focuses on repairing the disproportionate effect of the virus on people who live in poor communities, rather than the racial and ethnic inequities that are driving the health disparities in many counties.

It also focuses on issues that counties do not have short-term control over, he said.

“In essence, the metric does not provide us with a meaningful opportunity to show progress or lack of progress on the underlying issues related to COVID-19,” Matyas said.

Relucio, the Napa County health officer, said there was a lot of discussion between the state and the county health officers, including the California State Association of Counties, to develop the health equity metrics and “find metrics that we can all live with.”

She said what they came up with isn’t perfect but she appreciates that the state is trying to get people to understand how important health equity is, not just to the communities most impacted, but to the overall pandemic response. Counties need to address health disparities if they’re going to keep case counts under control, she said.

The metric makes it clear that addressing health disparities is going to require an “all-county” approach, she said, involving all sectors of the government and economy. “I think that’s the point the state is trying to get across,” Relucio said.

Communities of color have been devastated by the pandemic, accounting for a higher portion of cases and deaths in most Bay Area counties and across the United States.

Health experts and community advocates have said low-income people of color are particularly vulnerable because they often work essential jobs that prevent them from staying home. Many also live in crowded housing to afford high rents, which puts them at higher risk of contracting the virus, they said.

Marin County Public Health Officer Dr. Matt Willis said he understands the frustrations with the metric. But it sparks important conversations, and without it, the social and health inequities plaguing disadvantaged communities would simply persist, he said.

“It’s obviously extremely challenging to find a single indicator that encompasses inequities and the disproportional impact of COVID-19,” Willis said. “I applaud the goal of a measurable and specific indicator that actually influences the ability for counties to move forward.”

Under the new health equity metric, counties that report a lag between positive test rates must submit plans for funding and preventing spread of the coronavirus within these communities. Many said they plan to double down on contact tracing and testing efforts in the hardest-hit communities and developing programs that focus on culturally competent, bilingual care.

“As we target our public health response to the outreach and education about the behaviors that can keep residents safe, increasing access to testing particularly in our most impacted communities, and providing culturally competent contact investigation, we also know that the structural roots of these issues are much deeper and will require sustained attention over the years to come,” Louise Rogers, San Mateo County Health chief, said in a statement Thursday.

Sonoma County Health Officer Dr. Sundari Mase said the metric will not have a negative effect on the county’s reopening.

“Sonoma County welcomes the addition of this metric as it aligns with the county’s own focus on equity and addressing health disparities,” Mase said in a statement.

Health advocates applauded the state’s move, calling it an “essential and attainable element of our pandemic response.”

“By focusing our collective resources on the health and safety of the communities most impacted by the pandemic, we can safely move to reopen our state,” said a coalition of health advocacy organizations in a statement Thursday. “We encourage the state and counties to engage local community leaders in developing strategies to achieve the necessary progress, and to focus concurrently on the immediate pandemic response and on the systemic inequities in our state.”

Tatiana Sánchez and Erin Allday are San Francisco Chronicle staff writers. Email: [email protected], [email protected] Twitter: @TatianaYSanchez, @erinallday

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